Friday, April 4, 2014

#NephMadness, choices we made.

After next Tuesday, all that will be left
will be to send out the prizes.
NephMadness announces the finals today and the winner next Tuesday. As the field has contracted we have been feeling the pressure. People we respect have questioned our choices. Some have pointed to our final four, JNC8 and Acute PD in particular, and had some negative thoughts abut their importance.

I’m sorry they are disappointed with the final four. I personally am more concerned with the elite eight* than the final four, as the elite eight represents the champions of each region. The elite eight were:

  • Toxins: Aristolochic acid
  • Renal replacement therapy: Urgent PD
  • Hypertension: JNC8
  • Regeneration: pericytes
  • Acute kidney injury: Balanced fluids
  • Electrolytes: Bicarb in CKD

  • Stones: Acute Medical Care
  • Biologics: belatacept
* Any one else feel that the Final Four and the Sweet Sixteen, make it feel that eight should be an alliteration? But the sad reality is, elite and eight are not alliterative. I prefer Great Eight.

Looking over this list I am comfortable and enthusiastic about each choice (except for pericytes which I still don’t understand but Matt and I didn’t want a dream, bioartifical kidney, to win. When they can keep that Frankenstein Kidney alive for more than a few days without clotting we'll reconsider).


JNC8 is the most important issue in hypertension because it is leading a massive sea change in the blood pressure standards of hypertension around the world. JNC8 is largely in agreement with all of the national guidelines that have been published world wide.

For one, the start-treatment threshold of >150/90 mm Hg applies to patients 80 years or older in the ASH/ISH guidelines, as opposed to 60 years or older in JNC 8.
AHA/ACC/CDC joins JN8 in not calling for stricter, lower, blood pressure targets in the presence of CKD, diabetes, or proteinuria.

JNC 8 versus KDIGO

Everywhere hypertension experts have been reconsidering previous aggressive blood pressure targets. In the end, the blood pressure targets of JN8 are not based on firm data that fit every clinical scenario and we may end up revising them in the face of future data but these guidelines will determine the future of stroke, coronary disease, heart failure and kidney failure for millions of people being treated for hypertension.

Additionally, JNC8 and the ACC/AHA cholesterol guidelines together usher in a new era where observational data is no longer considered acceptable data to base guidelines. This resulted in a relaxation in both cholesterol and blood pressure targets. This is a sea change in how guidelines are developed. This is important. JNC8 also grades the evidence. E level evidence, i.e. expert opinion, on such a fundamental question as systolic blood pressure target, should be humiliating to the hypertension community. I believe that letter grade will stimulate the community to find the answers definitively. I salute the guideline writers for having the courage to admit that the emperor wears no clothes.

Urgent PD

Urgent PD triumphed in the renal replacement therapy region. We chose this because it is the first innovation in peritoneal dialysis in the last 20 years that seems capable of moving the needle and reversing the trend of dwindling number of patients on home therapy.

Two years ago there were one or two programs in the country, today there are over 100 urgen PD programs. PD, according USRDS is $20,000 a year cheaper to administer than HD and considering that 115,000 people initiate dialysis every year the savings quickly exceed my ability to track the zeros (9, I think). No one knows if PD is better than HD, and it probably is roughly equivalent, but it is definitely cheaper. Urgent PD is an innovation that shows promise in increasing the numbers of people in PD. After starting an urgent PD program we doubled our PD population after years of decline. When I mentioned that story to others who had urgent start PD programs they nodded their head and say the same was happening at their centers.

NephMadness Decisions

We did not make our decisions without thought and it is inevitable that others will have different values when it comes to these ambiguous and irrational comparisons. I am comfortable with the decisions that we made and do not feel we are limping to the finish line.
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